Click here to get more information about the fields on this form. FINANCIAL AFFIDAVIT JD-FM-6-LONG Rev. 2-16 P.B. §§ 25-30, 25a-15 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Court Use Only FINAFFL *FINAFFL* Use this long version if either your gross annual income is more than $75,000 (see Section I. Income) or your total net assets are more than $75,000 (see Section IV. Assets), or if both are more than $75,000. Otherwise, use the short version, form JD-FM-6-SHORT. For the Judicial District of Name of case Name of affiant (Person submitting this form) At (Address of Court) Instructions ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. Docket number - FA - - -S Plaintiff Defendant Certification I understand that the information stated on this Financial Statement and the attached Schedules, if any, is complete, true, and accurate. I understand that willful misrepresentation of any of the information provided will subject me to sanctions and may result in criminal charges being filed against me. I. Income 1) Gross Weekly Income/Monies and Benefits From All Sources Computed based on year-to-date, but no less than the last 13 weeks. If computation is based on less than 13 weeks or if your computations are not reflective of current wages, explain: Paid: Weekly Bi-weekly Monthly Semi-monthly Annually If income is not paid weekly, adjust the rate of pay to weekly as follows: Bi-weekly divide by 2 Monthly multiply by 12, divide by 52 (a) Job 1 Job 2 Job 3 Employer(s) Semi-monthly multiply by 2, multiply by 12, divide by 52 Annually divide by 52 Address(es) Salary Salary Salary Base Pay: Wages $ Wages $ Wages $ Total of base pay from salary and wages of all jobs............................................................................ $ (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) (m) (n) Overtime .............................................. Self-employment ................................... Tips...................................................... Commissions ........................................ Bonuses ............................................... Dividends ............................................. Interest................................................. Trusts................................................... Annuities .............................................. Pensions .............................................. Retirement/Tax Deferred Funds ............. Social Security ...................................... Disability............................................... $ $ $ $ $ $ $ $ $ $ $ $ $ (o) Unemployment ...................................... (p) Worker's compensation.......................... (q) Public Assistance (Welfare, TFA payments)............................................. (r) Child Support (Actually received)............ (s) Alimony (Actually received) .................... (t) Rental and income producing property.... (u) Royalties and other rights....................... (v) Contributions from household member(s) (w) Cash income ......................................... (x) Veterans Benefits .................................. (y) Other: $ $ $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com (z) Total Gross Weekly Income/Monies and Benefits From All Sources (Add items a through y) (Page 1 of 6) Hours worked per week Gross yearly income from prior tax year. Provide amount of income, not copies of forms ............................... $ List here and explain any other income including but not limited to: non-reported income; and support provided by relatives, friends, and others: 2) Mandatory Deductions (If consistent deductions don't occur every pay check provide average amounts.) (1) Federal income tax deductions (claiming exemptions) (2) Social Security or Mandatory Retirement (3) State income tax deductions exemptions) (claiming (4) Medicare (5) Health insurance (6) Union dues (7) Prior court order -- child support or alimony (8) Total Mandatory Deductions (add items 1 through 7) $ $ $ $ $ $ $ $ Job 1 $ $ $ $ $ $ $ $ Job 2 $ $ $ $ $ $ $ $ Job 3 $ $ $ $ $ $ $ $ Totals 3) Net Weekly Income.............................................................................................................................. $ Subtract the Total Mandatory Deductions [see item I., 2), (8)] from the Total Gross Weekly Income/Monies and Benefits From All Sources [see item I., 1), z) ] 4) Other Deductions (1) Credit Union Loan .................................. $ (5) Health Savings Account(s) or Plan(s)...... (2) Savings ................................................. $ (6) Deferred Compensation or 401K ............ (3) Retirement............................................. $ (7) Other Pre-Tax Deductions...................... (4) Subsequent Other Order of Court............ $ (8) Other Wage Executions ......................... (i.e., child support, alimony) (9) Total Other Deductions (add items 1 through 8) ............................................................................... $ $ $ $ $ II. Weekly Expenses Not Deducted From Pay If expenses are not paid weekly, adjust the rate of payment to weekly as follows: Bi-weekly divide by 2 Semi-monthly multiply by 2, multiply by 12, divide by 52 Monthly multiply by 12, divide by 52 Annually divide by 52 Insert an ("x") in the box if you are not currently paying the expense, or if someone else is paying the expense. Home: Rent or Mortgage (Principal, Interest -- Real Estate Taxes and Insurance if escrowed) Property taxes and assessments .......... $ $ 2nd Mortgage/Home Equity Line of Credit or Other Lien Household Improvements (Specify) $ $ Condominium Fees................................ Utilities: Telephone/Cell/Internet............................ Oil ........................................................ $ Electricity .............................................. Trash Collection ...................................... $ $ Gas ...................................................... T.V./Internet ............................................ Water and Sewer................................... $ Groceries (after food stamps): Including household supplies, formula, diapers ......................................... (Not including take out meals) Restaurants (Including take out meals)